The PicPod

Our patients are sick and it makes sense that they need lots of blood. Surely more blood means more oxygen to the tissues which is good… or is it? Why are things not so clear? When should we transfuse our patients? Why are transfusions bad? Is it the blood, the volume, or the variation in haemoglobin?

Recently published guidelines are very useful from the TAXI group, but how many questions are still unanswered?

Nutrition on children’s intensive care is difficult and is not always a priority. The focus is on survival and the ABC, not the niceties of feeding.

However our patients are in an extreme metabolic state and may well be catabolic. How do we prevent this and how do we improve outcomes?

Is the answer as obvious as just “stick the calories in” or is it more complicated than that?

In PicPod 12 we revisit some of the themes of PicPod 6. Sedation is difficult to get right, and we can do much harm if we give too much, or not enough. How bad are some of the drugs we use? How much are benzodiazepines linked to delirium?

Can we use music as sedation? As Bob Marley sang: “one good thing about music, when it hits you, you feel no pain”. Are there different types of music which work? Does it actually work, and what does the current research say in to this topic?

Played in by Bob Marley and played out by Johan Sebastian Bach, enjoy this one.

 

Picpod 11 puts it all in to context. Hans Jorg Lang is an intensivist who works with Medicins Sans Frontiers in a variety of countries in Sub Sahara Africa, including Malawi and Congo. Including a guest appearance by David Bird, an intensive care trainee.

What is the value of a child? How can we justify using ECMO when there are children dying because of a lack of basic medical care? Is this differential a way of the world, or is it unethical?

Any parent knows that their child is infinitely valuable. Are we actually trying to compare different infinities?

A thought provoking episode this one!

 

 

Picpod 10 is based on an interview with Pat Kochanek from Pittsburgh, who is also the editor in chief of PCCM. He has done much lab based and patient based work on traumatic brain injury, and talks about the next level of TBI treatments.

TBI is intensely frustrating: so much of the damage has been caused, and so much of the outcome is determined in the instant after the injury occurs. There is a raft of novel potential treatments coming, which all look promising, however this is against a background of dozens of viable treatments which have been shown to be ineffective in trials.

Or is it actually that we are discarding treatments due to inappropriate statistics? Should we accept a lower standard of proof in areas where absolute proof is unlikely to ever be found?

Enjoy this one: we did!

PicPod 9 features Joseph Manning, who specialises in research in to the family centered outcomes of PIC patients.

We get so caught up in the technicalities of our patients, do we forget to look after the wider family? Who looks after the siblings, and what damage might we be doing? Parents are, obviously, distracted by their very unwell child, and the sibling can be very much traumatised by this.

With excellent timing (see the NEJM publication of the PARAMEDIC2 study), Mike Shepherd from Starship Hospital in Auckland, New Zealand discusses the use of adrenaline in paediatric cardiac arrest.

Does it work? What does “work” mean? Is the outcome return of circulation, or should we also be thinking about neurological outcome? Is cardiac arrest research ethical, as we cannot take consent in these situations? Is adult data transferrable to children?

Welcome to PicPod 7. Martin Kneyber from the Netherlands was kind enough to talk to me in Singapore. He is part of the PROSpect trial, which is a 2×2 trial in to HFOV / conventional ventilation, and prone/supine positioning.

Should HFOV be abandoned? If not, why not? Why have adult ICUs abandoned it? If we use HFOV, how should we use it and when?

How sedated should our patients be? How should we sedate our patients? Two similar but actually different questions. Monique van Dijk from Rotterdam was part of a debate in Singapore: should patients be sedated more deeply, or should they have episodic agitation and distress? Which is worse, which is better?

Welcome to PicPod5: an interview with Ravi Thiagarajan from Boston Children’s PICU. Which is better as a rescue therapy: VVECMO or HFOV? Or something else entirely? Does anything work at all?

This was recorded after a live debate at the Singapore world congress.